Health Perception/ Management
Nutritional/ Metabolic
O (-) COPD
O (-) Diabetes Mellitus Type II
O (-) Failure
O (-) Hx Atrial Fibrillation
O (-) Early Alzheimer's
O (-) Right knee injury while in Navy
S (-) Fatigue; states he does not sleep
O (-) Skin: dry, with pruritus
O (-) Respiratory: Cough with greenish
sputum, dyspnea on exertion
O (-) Right knee injury while in Navy
O (-)Latex Allergy
O (-) Long term care- inability to manage
medical care in his home
O (-) Family unable to assist
O (+) 2000 Calorie Diabetic Diet
O (+/-) Height 5’8”
O (+/-) Weight: 148 lbs
O (+) BMI: 22.5
S (-) States preference for red meat
S (-) States preference for alcohol
O (-) 10lb weight loss in past 6 months
S (-) States decreased appetite due to difficulty
breathing
O (-) Upper/lower dentures
Activity/ Exercise
O (-) Increased Edema in Feet
O (-) Limited ROM in Right knee
O (-) Increased muscle weakness for past 6
months
S (+) States he enjoys puzzles and carpentry
Patient: Chester, Harry
Cognitive/ Perceptual
O (-) Early Alzheimers
S (+/-)Verbally states no depressive
symptoms
S (-) states he is “anxious about all the
changes in his life”
O (+) Awake, Alert, Oriented
O (+) normal speech pattern
Dx/CC: O (-) COPD, Diabetes Mellitus Type II,
Heart Failure, Atrial Fibrillation, Early Alzheimers
Vitals: Temperature - O (+) 97.5 F
O (+) Pulse - 88 bpm
Respiration Rate - 18 Resp/min
O (-) Blood Pressure - 167/88 mm Hg
Labs:
O (-) Blood sugar 120
Meds
O (+/-) Digoxin 0.25mg by mouth every day
NPH 25 U, SQ, q AM. NPH 10 U SQ q PM,
MS Contin 15 mg, q 12 hours,
O (+/-) Percocet 1-2 tabs q 4-6 hrs PRN pain,
Elimination
O (+) Wearing a diaper with a strong odor of
urine.
O (-) Occasionally incontinent of urine
O (-) Change in bowel pattern
S (+) Denies dysuria or urinary frequency or
urgency
O (-) wearing brief with strong scent of urine
Sleep/ Rest
S (-) Reports trouble sleeping, fatigue.
S (-) After waking wonders where his wife
slept
S (+) Denies night sweats
Self Concept
S (+) Values his relationship with his wife
S (-) Anxiety about changes
S (+) Likes putting things together, prior
carpenter
O (+/-) Regular Insulin Sliding Scale as follows:
< 50 drink 8 oz of regular soda or take 8-10 life
savers
51-100 no insulin needed
101-150 2 units
151-200 4 units
201-250 6 units
251-300 8 units
301-350 10 units
351-400 12 units and call MD
> 400
Call MD
Roles/ Relationships
O (+) Father of three adult children
O (+) Husband
O (+) Retired navy war veteran
Sexuality/
Reproductive
O (+) Genitalia normal
for age
S (+) States he loves his
wife
O (+) Married to a
female
Coping/ Stress
S (+) States no
depressive symptoms
S (-) states he’s anxious
about all the changes in
life
S (-) states he does not
sleep
Values/ Beliefs
.
O (+) Baptist
S (+) Devoted husband
Follow up questions
1. What do you pay attention to when making your decisions or how do you make them?(Coping/Stress)
2. What is your favorite thing to tell me about yourself lately?(Self Concept)
3. Can you share with me something that gives you meaning or strength in your life?(Values/Beliefs)